Foundation of the Pavilion of Sick Infants at the Maternity of Paris
“Fondation du Pavilllon des Enfants Débiles à la Maternité de Paris” [Foundation of the Pavilion of sick Infants at the Maternity of Paris]. Revue des Maladies de L’enfance, 142-154, 1908. Translation from French by Paul L. Toubas and Russel A. Nelson.
On 13th of July 1881, at the time of my appointment as midwife-in-chief at the Maternity, Pr. Tarnier, during my visit of the various services of the hospital, brought me up to date on the improvements and changes which he had obtained and those he was planning. He showed me in the wet nurse room, called the “crèche”, an incubator that he had arranged to be built. He explained the mechanism and told me the advantages which would benefit the infants born prematurely or feeble and asked me to help in his research and to start again the experiments he had done in the past. Everybody, today recognizes, not only the inocuousness of the incubator, but also the excellent results they are giving.
It was not the same in 1881; at that time, it was good to prove that a living individual was able to continue living in that device. The first infant was placed in an incubator almost dying; He was, thanks to the device been resuscitated, and survived. This first trial was a success, other infants were subsequently placed in it and survived.
These successes were soon recognized, not only in the medical word, but also in the lay public. The press took over the topic. From the point of view of the discovery and the services it was able to render, this publicity was excellent, but it produced, very quickly a dilemma. We were often brought infants born in the city; but we had only six incubators and five wet nurses; this was barely sufficient to accommodate the sick infants of the ” Maternity”. As it was impossible not to admit these infants at the nursery of the hospital, our service was soon overloaded.
To remedy this inconvenience, there was only one means, to create a special service. I talked to Mr. Tarnier: he supported and encouraged me a lot, but in order to realize this project, money was needed. I tried to establish a society which we called ” L’Oeuvre des couveuses”. It brought me with relative ease, subscriptions and few donations, about 10,000 Francs; this was insufficient. I searched out Mr. Peyron, Director general of ” Assistance Publique”; I told him about the logistic difficulties of the service of the crèche, he listened receptively, understood the importance of the foundation which I was soliciting, asking me to write everything that I told him, adding:” Find a little bit more money and we will help you.”- I then approached the Municipal Council of the city of Paris. Mr. Paul Strauss agreed to study the question and to present it to the Council. Mr. Peyron was consulted and gave a favorable advice, and in 1891, the establishment of the service was voted; a sum of 40,000 Francs, taken on the pari mutual betting was awarded.
The design of Mr. Rochet, architect of the Assistance Publique was adopted. It was decided that the pavilion will be constructed with masonry tiles. Mr. Imard (retired architect and inspector of the Assistance Publique) agreed to help us with its advice. When the pavilion was finished the costs exceeded by 17,000 Francs the initial project. The Council agreed to pay the difference.
Mr. Peyron, general director, Mr. Rousselle, president of the municipal council and Dr. Dubrisay, came to visit the new construction. They liked the inside, but disliked the grayish and sad exterior. To brake the monotony of the masonry tile , we ordered the application of lattices painted in green on which plants could entwine. The 10,000 Francs I had collected helped to pay for the heating system and other devices that the administration was not able to provide; in addition 14 incubators were built on the model designed by Mr. Tarnier with few additional modifications; finally we purchased an autoclave and everything needed to embellish the pavilion inside and outside. On July 20th 1893, the pavilion was open. I had the good fortune to direct the pavilion, to obtain the help of Mrs. Bataille, who combined the three qualities indispensable to all who must direct an hospital service: goodness, professional honesty and devotion. Thus the service functioned very well. There were never complaints on the part of the public nor any reproaches from the administration.
Unfortunately, for personal reasons, I was obliged to give my resignation and to leave the Maternity, abandoning thus the service which I had so much pleasure to create.
I left the hospital at the end of June 1895, but the pavilion of the weaklings was passed into other hands, but I did not take care of it any more and closed my statistics at the end of January 1 1895.
From July 20 1893 to January I 1895, we have received on the service of weaklings 721 infants; 364 were discharged in good shape and 357 died. Among these 357, 24 were born before viability. Fifteen had grave malformations, 68 were dying and died within 24 hours after their admission to the pavilion, a total of 107 infants. We believe , we need to exclude them in order to make a correct percentage. Therefore we are going to say: Of 614 infants, we had 250 deaths. We accepted all the infants that were brought to us., weaklings born prematurely or at term, and those , who, poorly fed , needed a good wet-nurse. We also admitted infants born before viability, not only to leave hope to the parents, but also to see if we would be able to take care of infants born at less than six months of gestation.
We had made an observation of an infant born at 5.5 months gestation , weighing 780 grams; he survived 13 days, he was able to suck a little and digested fairly well. Unfortunately he died of a cyanotic spell.
Between these to dates: July 20, 1893 and January 1, 1895, we have received 74 infants, in very poor condition, having been fed artificially.
Thirtty-eight times, we noted on the observation that the milk had been sterilized, 36 times this was not indicated.
Of these 38 infants fed with sterilized cow’s milk, 15 died, thus 39.4%.
Of the 36 observations without indication of the sterilization of milk, 16 died, thus 44 percent. Combining the 74 observations of infants artificially fed, we found 31 deaths, thus 41%.
What is the disease which would give a comparable statistic?
All these infants died of enteritis and similar infections; however a proportion of them came from hospital services were that mode of feeding was part of the feeding protocol and probably properly carried out.
When you have observed the agony of these little creatures, you wonder why this type of feeding is still advertised.
Already, in 1883, Mr. Tarnier had us sterilized the milk which was given to infants born at the Maternity. This milk was placed in an American cooker. To carry it at more than 100 degrees Celsius, he made us use oil , the water supplemented with sodium chloride. He hoped to insure complete sterilization of the milk.
In this manner, we tested sterilized milk undiluted with one-third or one-half water, and finally milk sterilized with unsalted beef broth in equal parts.
The American cookers remained one hour in the boiling liquid. When the lid was raised, there was no cream on the milk. It was immediately poured in small glass bottles containing 50 to 60 grams which served to feed the infants.
With these different preparations, we have nourished a certain number of infants. With some of them , we have been able to continue artificial feeding up to two weeks or more. The condition of the infant has always caused us to interrupt the feeding momentarily or definitively, to replace it by breast feeding direct, or gavage, either because the infant was loosing weight or had too much diarrhea.
All these observations have been controlled by Mr. Tarnier; on each page of the chart we have noted the preparation used, the number and the hours of feeding, the quantity of milk taken in 24 hours, the condition of the infant, his temperature in the morning and the evening, the number and the appearance of the stools. For 90 of these observations, I copied , every day, with water color the color of the stools. All these water colors were also seen by Dr. Tarnier, who compared them to the to the diaper of the infant. You will find a specimen along with that study.
Every morning and evenings, the infant under observation was weighted; the graphic tracing is very interesting. In direct feeding by a mercenary wet-nurse, 5 or 6 days after birth, the infant had regain his initial weight. If he is fed by his mother, specially if she is feeding for the first time, this weight is only gained around the ninth or tenth day. With artificial feeding, it is rare that it rare that weight is regained at that time.
All the research that we have done brought us to the conclusion that artificial feeding was particularly dangerous during the two months following birth. We are convince that it is wrong to believe that sterilization of cow’s milk avoid all these dangers. In infants fed that way , we have seen often green diarrhea and we have always been surprised by the foul smell of the diapers and vomiting; we have most of the time observed abdominal distention and persistent erythema. In the mixed feedings, the prognosis is more favorable, this mode of feeding, if breast feedings periods are more numerous, succeeds well. In that case the milk and the unsalted broth (1) sterilized together (10, 20 30 grams before breast feeding) gave us relatively good results in the newly born infant. On 62 infants fed in that fashion, 59 were discharged in good condition, 3 died.
Mr. Michel, resident of Mr. Prunier, pharmacist of the Maternity, did in 1894 some experiments on the artificial digestion of milk. We gave him two samples; one of pure sterilized cow’s milk, the other of milk and unsalted broth, diluted 50% and sterilized. He did not know the content of the two bottles, they were only identified by bottle Nr. 1 and bottle Nr. 2. Here are the results he obtained.
Artificial digestion of two milk samples given to Mr. Michel on January 8 1894.
Sample size… 100mL
Addition of … 0.50 gm HCl.
1 gm of amyloid pepsin from the Codex.
Digestion: about three hours at 40°C.
10 ml of each such treated samples are evaporated at 100°C. ( after filtration) until complete desiccation.
The Nr. 1 sample (pure sterilized milk) leaves 0.719 of dry residue containing peptones and the soluble materials of the milk.
The Nr. 2 (milk and broth sterilized) leaves 0.616 gm of residue. The two samples were sterilized with the autoclave.
In the same conditions as the first, but the duration of the digestion was 4 hours. The Nr 1 sample left 0.875 gm of residue, the Nr. 2 left 0.750 of residue.
These two assays are in agreement to demonstrate the superiority of Nr. 2 on the amount of principal components held in dissolution. Did these components preexisted in the milk of were they the product of digestion?
New experiments are necessary to take into account additions made to the milk.
Remarks and Observations Done at the Pavilion of the Feeble
Some diseases are more frequent in prematurely born infants or weaklings than others. Those we have most commonly observed at the nursery of the maternity included:
- Some diseases of the respiratory and digestive tube.
These diseases are well known, except two, perhaps which still are not, we believe, completely studied. The first which we are going to talk about is an non syphilitic affection of the nasal fossa. It is relatively frequent in feeble infants and must show: 1) the difficulty which they have with swallowing 2) the ease with which they vomit. In these two cases, they frequently reject milk through the nose; a little bit of this milk stays in the upper part of the pharynx and the posterior part of the nasal fossa mixing itself with secretions, alters itself and ferments quickly. Mucous membranes, on which it is deposited are irritated and inflamed. One sees then coming from the nares a purulent discharge; if one is unable to disinfect these a focal areas, the tissues change more and more, the skeleton of the noses is deformed, flattens, the nasal bridge gets depressed, the shape of the nose appears to be changed like if it was broken. The nose will keep forever this shape. It is deformed as it is in syphilitic ozena.
All these little patients do not heal; a certain number dye of cyanotic spells or broncho-pneumonia and present some days before their death a swelling of the upper lip and the tissues of the face. At autopsy, one finds the nasal fossa filled with putrid material, with underneath ulcerations of the nasal mucosa. Nothing , after cut of the brain, resembles syphilitic lesions.
Nasal lavages are indicated, but this is difficult to do. We use cotton soaked in boric water and inserted as far as possible. We also apply Vaseline mentholated or borated. At the moment I left the Maternity, I wanted to make an instrument to insert more deeply the small tampons. My departure made me abandon the project.
Other infants, affected in the same way, die , we have said of broncho-pneumonia. This infection, well localized in the posterior region of the nasal fossa, may invade other organs and produce deadly complications. On the point of view of repercussions of localized infections influencing the general health of the infant, this disease may be compared to ophtalmia of the newborn.
We have made a review of last disease and we found 45 cases of ophtalmia that 15 died of pneumonia, or seizure without appreciable meningitis.
In newborn infants, germs are able to penetrate easily by five ways: the eyes, the nose, the mouth, the navel and ears (this fifth entry was reported by Dr. Pinard.)
Therefore all these areas should be the object of attentive surveillance, specially during the first fifteen days following birth. Because some infants may have only light infections, in some others , it may be quite severe. These occurences could be localized, either because the infant is in a better state of defense or that through appropriate treatment, the diffusion of the disease can be prevented. But in other cases the infection spreads, reaching the neighboring organs and leading to lethal complications.
We have sometimes observed metastatic abscesses from other causes, except, that a mild infection of the regions we have described.
Among the infections of the respiratory apparatus, there is one which is difficult to appreciate. We want to speak of the cyanotic spells which one notes so often in the premature infant which is not accompanied with auscultation signs and it which at autopsy one finds nothing in the lungs to explain this. This cyanosis of the newborn we believe depends on two causes, one of neurological origin and the other mechanical.
Neurological origin.- With this cause, the apneic spell originates without preludes; the infant , in his incubator or in his cradle is of a pink more or less bright color, breathing regularly, appears to be sleeping, then suddenly stops to breathe; his color becomes gray, then blue, then near black. If one is not able to give him artificial breathing, he dies.
We believe that we can attribute to this cause the demise of infants found dead in their bed.
Prognosis.- It is very serious; however, we have seen certain number of infants heal despite many cyanotic spells.
Treatment.- During the spell, insufflation and skin stimulation. Warm baths, frictions of alcohol are sufficient. Under the influence of these treatments, one sees little by little the respiration become regular and the child regains color.
In the intervals of the spells, it is necessary to give close observation to the little sick one. Do not over feed the infant. In these cases we have found advantageous to give some hot rum, one or two tea spoon before the feeding; we successfully used ozone and oxygen inhalation (see the thesis of Dr. Patel 1895) and subcutaneous injections of testicular liquid, two injections a day of 10 drops each. In 20 infants, receiving these injections, 13 were discharged in good health and 7 died.
Cyanosis of Mechanical cause.- The apneic spells in these cases are due: to abnormal development of the stomach and or the intestines. These organs, too, compressed in the abdominal cavity, push the diaphragm and impede diaphragmatic movements and diminish the capacity of the thoracic cavity.
This condition is observed in overfed infants and often in those who are nursed with a milk specially rich in casein like that is seen in artificially fed infants.
In that case, we have seen the suffocation spells after abundant vomiting in which often one can find more or less large clots of casein.
The look of the infant has no resemblence to the one we have described in cyanosis of neurologic origin. With that latter condition spells are also observed, but he is not flaccid. In general after the vomiting, the spells stops, the child returns to pink. The prognosis is grave but but less grave than that of cyanosis of neurologic origin.
Treatment.- The treatment of the spells consist of artificial respiration of the infant. But in that case, we believe that tractions of the tongue are better than insufflations; stimulation of the skin may be of great help. In the interval of the spells , treat the digestive problems and change the feedings of the child.
Each time that a difficult case present in the pavilion of the feeble, Mr. Gueniot, Surgeon in Chief of the maternity and Mr. Labadie Lagrave, physician of the hospital, gave us a generous help with their advice and we owe them a great part of the success that we have had in the service. We ask them to receive our sincere thanks.